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  • 1. C.O.P.D.
  • 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE
    • Definition
    • Chronic Obstructive Pulmonary Disease (COPD) is a chronic slowly progressive disorder characterized by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy.
  • 3. EMPHYSEMA
    • Centriacinar - Centrilobular
    • Panacinar - Panlobular
    • Periacinar - Paraseptal or distal Acinar
  • 4. CHRONIC BRONCHITIS
    • Simple mucoid bronchitis
    • Mucopurulent bronchitis
    • Chronic obstructive bronchitis.
  • 5. PATHOLOGY
    • Changes in Mucus gland thickness
    • Air Flow limitation due to:-
    • (i) Mechanical obstruction.
    • (ii) Loss of pulmonary elastic recoil.
    • (iii) Reduction of the alveolar attachment around the walls of the small air ways
    • Circulatory changes are confined to advanced disease.
  • 6. CLINICAL FEATURES
    • Symptoms include cough, sputum, dyspnoea, and wheeze.
    • Signs: Pink puffers & blue bloaters (2 ends of a spectrum).
    • Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea.
  • 7. SYMPTOMS TYPICAL OF COPD
    • History of heavy smoking for many years.
    • Cough and sputum production for many years.
    • Cough often present only on waking at first; later cough occurs throughout the day.
    • Sputum usually mucoid – becomes purulent with exacerbation of disease, but not excessive.
    • Cough and sputum often worse in winter due to infection.
    • Insidious onset of breathlessness on exertion with wheezing or tightness of chest.
  • 8. SYMPTOMS TYPICAL OF COPD (CONTD.)
    • Some develop increasingly severe exacerbations of disease leading to chronic respiratory failure and heart failure – the “blue bloater’ type of COPD.
    • Others have little or no sputum or hypoxia at rest, but breathlessness and wheezing is severe and emphysema is prominent – the pink puffer’ type of COPD. These patients are commonly underweight.
    • Most patients with COPD present with a mixed pattern rather than the ‘blue bloater’ or ‘pink puffer’ extremes.
  • 9. SYMPTOMS NOT TYPICAL OF COPD
    • Haemoptysis – can occur due to COPD alone, but its appearance is such a patient suggests the possibility of malignancy, which must be carefully sought.
    • Seasonal exacerbations in spring or summer are more likely in asthma.
    • Excellent response to bronchodilators or steroids with definite symptom-free intervals is suggestive of asthma, not COPD.
  • 10. SYMPTOMS NOT TYPICAL OF COPD (CONTD).
    • Continuous expectoration of purulent sputum is more typical of bronchiectasis than COPD.
    • Breathlessness without productive cough or wheezing is more typical of cardiac disease or of other lung diseases such as interstitial pulmonary fibrosis..
  • 11. PHYSICAL EXAMINATION
    • Large, barrel-shaped chest.
    • Prominent accessory respiratory muscles in neck.
    • Low, flat diaphragm causing costal margin retractions on inspiration.
    • Diminished breath sounds, distant heart sounds.
    • Prolonged expiration with generalized wheezing predominantly on expiration.
  • 12. PHYSICAL EXAMINATION (CONTD).
    • Depressed liver, which is not enlarged.
    • The ‘blue bloater’ type of COPD patient may also have:
      • Cyanosis at rest or mild exertion.
      • Oedema of ankles
      • Crackles at lung bases.
      • Loud second heart sound in pulmonary area (difficult to hear in COPD).
    • The ‘pink puffer’ type of COPD patient may also have:-.
    • expiratory pursed-lip breathing, thin body build and tendency to lean forward over a support to assist breathing.
  • 13. RADIOLOGY
    • Plain chest radiography
    • 1. Signs due to hyperinflation.
    • 2. Signs due to vascular changes.
    • 3. Signs due to bullae.
    • 1. Low flattened diaphragms.
    • 2. Increase in the retrosternal space.
    • 3. An obtuse costophrenic angle.
    • 4. A reduction in size and numbers of
    • pulmonary vessels. Particularly in the
    • periphery of the lung.
    • 5. Vessel distortion producing increased
    • branching, angles or bowing of vessels.
  • 14. C.T. SCAN CHEST
    • Areas of low attenuation without obvious margins or walls.
    • Attenuation and pruning of the vascular tree.
    • Abnormal vascular configuration.
    • C.T. Scan is the most sensitive and specific imaging technique for assessing Emphysema.
  • 15. DIAGNOSIS
    • Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.
  • 16. DIAGNOSIS (Contd.)
    • For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation. FEV 1 / FVC < 70% and a postbronchodilator FEV 1 < 80% predicted confirms the presence of airflow limitation that is not fully reversible.
  • 17. Additional Investigation
    • Bronchodilator reversibility testing
    • Glucocorticosteroid reversibility testing
    • Chest X-Ray
    • Arterial blood gas measurement
    • Alpha - 1 antitrypsin deficiency screening
  • 18. Differential Diagnosis
    • Asthma
    • Congestive Heart Failure
    • Bronchiectasis
    • Tuberculosis
    • Obliterative Bronchiolitis
  • 19. Causes of Chronic cough with a normal Chest X-ray
    • Intrathoracic
    • Chronic obstructive pulmonary disease
    • Bronchial asthma
    • Central bronchial carcinoma
    • Endobronchial tuberculosis
    • Bronchiectasis
    • Left heart failure
    • Interstitial lung disease
    • Cystic fibrosis
  • 20. Causes of Chronic cough with a normal Chest X-ray
    • Extrathoracic
    • Postnasal drip
    • Gastroesophageal reflux
    • Drug therapy (e.g. ACE inhibitors)
  • 21. Management of COPD
    • Assess and Monitor Disease
    • Reduce Risk Factors
    • Manage Stable COPD
    • Manage Exacerbations
  • 22. Therapy at Each Stage of COPD
    • Stage Characteristics Recommended Treatment
    • All * Avoidance of risk factor (s)
    • * Influenza vaccination
    • 0: At risk * Chronic Symptoms
    • (cough, Sputum)
    • * Exposure to risk factors
    • * Normal spirometry
    • Mild COPD * FEV 1 /FVC < 70% * Short-acting bronchodilator
    • * FEV 1  80% predicted when needed
    • * With or without symptoms
  • 23. Therapy at Each Stage of COPD
    • Stage Characteristics Recommended Treatment
    • Moderate COPD FEV 1 40 - 59% * Regular treatment * Inhaled Gluccocorti -
    • with one or more costeorodis if
    • bronchodilators Significant
    • * Rehabilitation Symptoms and lung
    • function response
  • 24. Therapy at Each Stage of COPD
    • Stage Characteristics Recommended Treatment
    • Severe COPD FEV 1 < 40% * Regular treatment with one or more
    • bronchodilators
    • * Inhaled glucorticosteroids if significant
    • symptoms and lung function response or
    • if repeated exacerbations.
    • * Treatment of complications
    • * Rehabilitation
    • * Long-term oxygen therapy if respiratory
    • failure.
    • * Consider surgical treatments.
  • 25. Manage Exacerbations
    • Common Causes of Acute Exacerbations of COPD
    • Primary
    • Tracheobronchial infection
    • Air pollution
    • Secondary
    • Pneumonia
    • Pulmonary embolism
    • Pneumothorax
    • Rib fractures/chest trauma
    • Inappropriate use of sedatives, narcotics, beta-blocking agents
    • Right and/or left heart failure or arrhythmias
  • 26. Management of Acute COPD
    • Controlled oxygen therapy
    • Start at 24-28%; vary according to ABG
    • Aim for a PaO2 >8.0 kPa with a rise in PaCo2 <1.5kPa
    • Nebulized bronchodilators:
    • Salbutamol 5mg/4h and Ipratropium 500 µg/6h
    • Steroids
    • I/V hydrocortisone 200 mg and Oral Prednisolon 30-40 mg
  • 27. Management of Acute COPD (Contd.)
    • Antibiotics:
    • Use of evidence of infection: e.g. amoxicillin 500 mg/6h P.O.
    • Physiotherapy to aid sputum expectoration
    • If no response: Repeat nebulizers and consider I/V aminophyllin ↓
  • 28. Management of Acute COPD (Contd.)
    • If no response:
    • 1. Consider nasal intermittent positive pressure ventilation if respiratory rate >30 or pH <7.35. I is delivered by nasal mask and a flow generator ↓
    • 2. Consider intubation2 & ventilation if pH<7.26 and PaCO2 is rising
    • 3. Consider respiratory stimulant drug e.g. doxapram 1-2 mg/min IV. SE: agitation, confusion, tachycardia, nausea Only for patients who are not suitable for mechanical ventilation A short – term measure only
  • 29. Management of complications
    • Acute exacerbations.
    • Chronic respiratory failure
    • Acute respiratory failure
    • COR pulmonale
  • 30. PULMONARY REHABILITATION
    • Education about the disease process.
    • Breathing retraining.
    • Exercise training.
    • Proper use of mediations and oxygen.
    • Nutritional support.
    • Psychological support.
  • 31. Future trends
    • New technologies i.e. (NIPPV)
    • Early detection
    • New therapies
      • ą 1 – antitrypsin replacement therapy
      • New anticholonergics. i.e. Tiotropium bromide
      • Enzyme/mediator inhibitors i.e. Specific neutrophil elastase inhibitors
      • Anti-inflammatory treatment i.e. phosphodiesterase (PDE) type 4 inhibitors